RN Utilization Review

UofL Health•Louisville, KY

1d•Onsite

About The Position

The Utilization Review RN performs activities that support Utilization Management functions. They are responsible for the delivery of the Utilization Management process, including making clinical recommendations regarding medical necessity for admission and continued stay, screening patients based on client-specific guidelines for insurance, Medicare, and/or Medicaid, and sending payor-specific Notice of Admission and continued stay reviews. The role involves communicating with physicians and case managers regarding payor approval/denial of admission and continued stay reviews, processing payor denials and retro reviews, promoting optimal health care outcomes in accordance with UofL Health's policies, procedures, applicable laws, contracts, philosophy, mission, and values. The employee assumes responsibility and accountability for the appropriate utilization of facilities and services and serves as a resource to physicians. They conduct admission and concurrent reviews, identify patients who do not meet criteria, and take action to ensure patients are cared for at the most appropriate level of care. This role coordinates care with the interdisciplinary healthcare team to provide and facilitate optimal health and financial accountability, utilizing the nursing process and management process for decision-making. They maintain confidentiality, actively support organizational goals, and participate in ongoing UM competency validation and regulatory education.

Requirements

ADN or Associate’s degree in nursing (Required)
Two (2) years’ experience as an RN (required)
Three years’ experience with Behavior Health experience (required for positions at Peace Hospital)
Active Kentucky Registered Nurse License or compact license with privileges to work in Kentucky
Must be able to adjust priorities quickly, organize multiple tasks simultaneously, and work interdependently with many levels of staff
Attention to detail; strong organizational, interpersonal and communication skills; and innovative problem-solving skills required
Maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to utilization review
Knowledgeable of state laws, CMS conditions of participation, and TJC standards regarding regulatory requirements for care management and utilization management
Knowledgeable of the services lines and uses sound nursing judgement and adheres to the code of professional conduct.
Understands and can exhibit RN licensure scope of practice
Must be able to adjust work hours depending upon departmental and organizational needs as determined by the director or manager of care coordination or the CNO
Functions within RN scope of practice and UM policies; adhere to CMS Conditions of Participation and Payer requirements.
Able to critically think through complex patient situations, process improvements, evidence-based practice
Able to assist others in developing clinical reasoning skill
Able to break down problems or tasks; scanning one’s own knowledge and experience to identify causes and consequences of events
Proficient in Microsoft Word, Excel and Outlook
Basic computer skills including the use of electronic medical records
Must have the capacity to learn other relevant systems and databases, as needed
Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor always
Maintains confidentiality and always protects sensitive data
Adheres to organizational and department specific safety standards and guidelines
Works collaboratively and supports efforts of team members
Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community

Nice To Haves

Bachelor of Science in Nursing (preferred)
An RN with a bachelor's degree in business, Health Care Administration or equivalent on the condition that they enroll in a BSN program within one year of employment and complete the BSN within three years of employment
Additional (1) year experience in case management/utilization management (preferred)
Case Management Certification (ACM, ANCC-Nurse Case Manager or CCM) preferred

Responsibilities

Promotes optimal management of clinical resources by conducting timely admission and concurrent utilization review for all patients of designated medical services.
Certifies medical necessity for admission, continued stay, and discharge reviews for patients certified by utilizing the current MCG criteria.
Documents clinical information in the Case Management Software system.
Evaluates the medical record during the concurrent review process to identify any process delays impacting the timeliness of patient care in a collaborative effort to ensure that appropriate resources are utilized (e.g., physical therapy, cardiac rehabilitation, or nutritional service).
Supports the utilization review program by maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.
Communicates closely with third-party payors to ensure all pertinent clinical information is provided to secure an authorization.
Appropriately documents information regarding the authorization number and the approved length of stay on the Case Manager Software.
Advocates for patient/family needs in a respectful, non-judgmental, and confidential manner.
Serves as a resource to physicians for clinical management and financial issues.
Assists providers with promoting efficiencies in the care delivery system and reducing/eliminating barriers to efficient/effective service.
Reviews patient cases for potential problems with OIG Workplan Audits and compliance issues; reports problems and makes recommendations to appropriate departments.
Appropriately refers cases to manager/director of care coordination, CAO, or medical director when intensity of service or severity of illness is not present and is unable to be resolved.
Educates physicians, patients, and staff regarding payors, financial issues, documentation, and potential compliance issues.
Investigates and responds to billing concerns from Business Office, Health Information Management, Admitting, and other sources; resolves financial and billing problems, such as appropriate patient status, correct payor source, denials, appeals, and system issues.
Develops a cooperative, assistive relationship with third-party reviewers, working to facilitate timely, positive responses for patient accounts.
Attends Monthly Departmental Staff Communications Meetings.
Serves as an active member of committees, as needed, which may include a variety of projects or topics.
Enhances professional growth and development through participation in educational programs, reading current literature, attending in-service meetings and workshops related to assigned areas of responsibility.
Maintains compliance with all company policies, procedures, and standards of conduct.
Complies with HIPAA privacy and security requirements to always maintain confidentiality.
Performs other duties as assigned.